Cardiac tamponade as presenting symptom of tuberculosis.

To cite: Zadra AR, Ripellino P, Barzaghi N. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208787 DESCRIPTION A middle age man was admitted to our infectious diseases department with recent weight loss, fever, dyspnoea and palpitations. Blood and urine tests showed only increased C reactive protein and mild anaemia. As the patient’s wife was previously diagnosed with pulmonary tuberculosis (TB), we performed an interferon γ assay (QuantiFERONTB-2), which turned out to be positive. Sputum specimens revealed the presence of Mycobacterium tuberculosis, and TB chemotherapy (isoniazid, rifampicin, pyrazinamide and ethambutol) was immediately started. A chest and abdomen CT scan could not detect pulmonary lesions, but revealed multiple masses infiltrating the right atrium and ventricle up to the outflow tract. A few days after admittance, the patient developed heart failure because of reduced right ventricle inflow, visualised by transoesophageal echocardiography and MRI (figure 1), associated with atrial fibrillation with fast ventricular response. He was transferred to the intensive care unit for mechanical ventilation, haemodynamic support with fluids and amiodarone for rate control; he eventually required urgent cardiac surgery for repair of the inflow obstruction. The histological examination of the cardiac mass resulted positive in the Ziehl-Neelsen staining, and the diagnosis of cardiac tuberculoma was made. Recovery from cardiac impairment was slow, and the patient received antitubercular chemotherapy for a total of 6 months. At 9-month follow-up, he did not require further antiarrhythmic drugs and the cardiac MRI (figure 2) showed a single residual chronic intramural non-active lesion, without any effect on cardiac filling.